Periodontal Teledentistry Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Patient ID: ____________________

Consent for Teledentistry Services

I, _________________________, hereby consent to receive periodontal care services via teledentistry from [Practice Name] and its affiliated dental healthcare providers.

Understanding of Teledentistry Services

1. I understand that teledentistry includes:

   • Live video consultations
   • Review of submitted photos and videos
   • Digital exchange of periodontal records
   • Remote monitoring of periodontal conditions

2. I acknowledge that:

   • Teledentistry is not a substitute for all in-person periodontal care
   • Some conditions will require physical examination
   • Technical difficulties may disrupt or delay services
   • Emergency situations require in-person care

Privacy and Security

• All teledentistry sessions are conducted through HIPAA-compliant platforms
• Electronic communications will be encrypted
• Sessions will not be recorded without separate explicit consent

Financial Responsibility

I understand that:

• Insurance coverage for teledentistry may vary
• I am responsible for any uncovered charges
• Payment is expected at time of service

Signatures

Patient Signature: ___________________ Date: ________

Provider Signature: __________________ Date: ________

Contact Information

Emergency Contact: _______________ Phone: _________________________

Practice Emergency Line: __________